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The letter and spirit of a directive [1]
1Director of the Neiswanger Institute for Bioethics & Health Policy at the Stritch School of Medicine, Loyola University Chicago.
The Virtual Mentor : VM
|December 28, 2012
Abstract
No abstract available in PubMed .
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Quality documentation and reporting share essential characteristics that ensure they are practical and valuable resources for those who use them. These characteristics are:
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Factual:
The following points emphasize the significance of upholding accurate and unbiased documentation in healthcare.
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Patient outcomes reflect the patient's response to the goal rather than what the nurse aims to achieve. Terminology should be observable and measurable to avoid the reader's interpretation. The desired outcome should be realistic and achievable in the designated care timeframe. Expected outcomes should align with adjunctive therapies. The outcome should enhance care evaluation by...
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Effective documentation is an integral part of nursing practice. Here are some essential guidelines to follow when documenting patient care:
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